Patterns of adolescent chewing betel nut
and later drug use in adults
Yu-Ching Lan1,2 Yi-Ing Hser3 Yin-Kon Ho1 Wen-Ing Tsay4 Jaw-Jou Kang 4
1. Center for Drug Abuse, China Medical University Hospital
2. Department of Health Risk Management, School of Management, China Medical University 3. UCLA Integrated Substance Abuse Programs
4. Taiwan Food and Drug Administration
Introduction
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Baseline Results
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The chewing of betel nut, a combination of areca nut, betel leaf, slaked lime, and region dependent flavoring ingredients is a uniquely Asian, culturally derived lifestyle habit. Bred from ancient tradition, its use is socially accepted in all groups, including women and young children, although other substance use such as tobacco smoking is deemed objectionable.1,2 The Asian Betel-quid Consortium study showed the chewing prevalence rates in Asian men were during 9.8% - 43.6%, which higher than women during 1.8% - 46.8% in 2009.3 By raising epinephrine and norepinephrine plus modulation of cholinergic and monoamine transmission, areca nut exerts neurobiological effects on the sympathetic and parasympathetic nervous systems.4-6 Tolerance and withdrawal symptoms have been detected in regular betel nut chewers.7-9 Such a pharmacological profile is comparable with nicotine, a well-known substance that leads to abuse and dependence. This suggests that betel nut chewing may be like cigarette or alcohol has ‘gateway effect’. But, its gateway pattern between betel nuts chewing and illegal drug use had not been examined clearly in previous studies.
Objectives: Our studies tried to address the timeline of gateway effect among betel nuts and illicit drug use.
Study Design
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Data Source and Study Subjects
Secondary Data are from the 2005 and 2009 National Health Interview Survey and the claims data in the National Health Insurance Research Database in Taiwan. We used the data containing personal socioeconomic status and addictive materials information including history of smoking, drinking, chewing betel nuts and material use behaviors. There were 14958 and 16563 adult subjects who completed the 2005 and 2009 substance abuse surveys.. We measure these adults’ substances usage patterns. For understanding which kind of substances usage pattern inducing their drug abuse risk in adult, we compared different substances use situation among drug user and non-users in 2005 and 2009 surveys.
Statistical Analysis
We used SAS (version 9.2 for windows; SAS Institute Inc., Cary, NC, U.S.A.) for all statistical analyses. Differences in demographic characteristics between subjects in 2005 and in 2009 were observed by chi-square test for categorical variables and Wilcoxon two-sample test for continuous variables. Differences of the proportion of substance abuse between 2005 and 2009 were examined by chi-square test. Brown-Mood test was used to examine the differences of age at onset for substance use between drug abusers and non-drug abusers. Logistic regression models were used to measure odds ratios with 95% confidence intervals (CIs). Demographic characteristics that were associated with illicit drug abuse in the univariate analysis were included in the multivariate regression model for adjustment.
Betel nuts consumption in Taiwan
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The decreasing trend of betel nuts consumption in Taiwan during 1991-2010
The main agricultural products in Taiwan are rice, sugar cane, betel nuts and corn. According to the latest statistics published by the Taiwan Directorate General of Budget, the Taiwanese betel nuts consumption was decreasing from 10.4 kg/year in 1995 to 7.2 kg/year in 2010 which almost down the similar level in the year 1991.
7.7 10.4 10.5 9.9 9.6 9.3 8.3 7.9 8 7.5 8 7.8 7.2 0 2 4 6 8 10 12 1991 1995 1996 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Conclusion
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This study examined the onset age of betel nuts chewing and considered the possible association between betel nuts using and becoming illicit drug use later in adult. Similar with cigarette and alcohol, the onset age of 18 among illicit drug users was younger than non-illicit drug users in the age 20 (p<0.001). Later the teenager use the betel nuts, smaller risk they would develop illicit drug using later in adult (OR 0.92(0.88,0.96) in 2005; 0.95(0.92, 0.98) in 2009). Furthermore, the one year increasing in betel nuts use duration, there was 1.11(1.09, 1.13 ;95%CI) odds becoming illicit drug users later in adult.
For adolescents who become daily betel nuts chewer, quitting for 18 years old or
decreasing the chewing duration should be the aim of betel nuts and other addict
substance control and intervention.
1. Strickland SS. Anthropological perspectives on use of the areca nut. Addict Biol 2002;7:85-97.
2. Changrani J, Gany F. Paan and Gutka in the United States: an emerging threat. J Immigr Health 2005;7:103-8.
3. Lee CH, Ko AM, Warnakulasuriya S, Ling TY, Sunarjo, Rajapakse PS, et al. Population burden of betel quid abuse and its relation to oral premalignant disorders in South, Southeast, and East Asia: an Asian Betel-quid Consortium Study. Am J Public Health 2012;102:e17-24.
4. Winstock A. Areca nut-abuse liability, dependence and public health. Addict Biol 2002 ;7:133-8.
5. Lord GA, Lim CK, Warnakulasuriya S, Peters TJ. Chemical and analytical aspects of areca nut. Addict Biol 2002;7:99-102. 6. Chu NS. Neurological aspects of areca and betel chewing. Addict Biol 2002;7:111-4.
7. Winstock AR, Trivedy CR, Warnakulasuriya KA, Peters TJ. A dependency syndrome related to areca nut use: some medical and psychological aspects among areca nut users in the Gujarat community in the UK. Addict Biol 2000;5:173-9.
8. Benegal V, Rajkumar RP, Muralidharan K. Does areca nut use lead to dependence? Drug Alcohol Depend 2008;97:114-21.
Reference
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Table 1. Demographic data for random samples of people aged 18~64 years from 2005 and 2009, frequency (%) Variable 2005 2009 P-value N=14598 N=16563 Age Mean (SD) 38.9 (12.5) 39.1 (12.7) 0.1771 Gender Male 7713 ( 51.6%) 7859 ( 47.4%) <0.0001 Female 7245 ( 48.4%) 8704 ( 52.6%)
Living Area North 3536 ( 23.6%) 4180 ( 25.2%) <0.0001
Centre 712 ( 4.8%) 1081 ( 6.5%)
South 6110 ( 40.9%) 5809 ( 35.1%)
East 4594 ( 30.7%) 5491 ( 33.2%)
Marital status Married 5945 ( 39.8%) 7099 ( 42.9%) <0.0001
Single 9000 ( 60.2%) 9462 ( 57.1%)
Academic degree None 150 ( 1%) 296 ( 2%) <0.0001
Elementary school 2061 ( 13.9%) 0 ( 0%)
High school 7365 ( 49.7%) 7713 ( 52.5%)
College or above 5253 ( 35.4%) 6687 ( 45.5%)
Academic degree of father None 628 ( 5.1%) 3466 ( 32.7%) <0.0001
Elementary school 6112 ( 49.6%) 0 ( 0%)
High school 4362 ( 35.4%) 5373 ( 50.7%)
College or above 1230 ( 10%) 1766 ( 16.7%)
Academic degree of mother None 495 ( 5.1%) 5943 ( 54%) <0.0001
Elementary school 5568 ( 57.8%) 0 ( 0%) High school 3131 ( 32.5%) 4238 ( 38.5%) College or above 440 ( 4.6%) 819 ( 7.4%) Occupation None 3094 ( 21%) 4324 ( 26.2%) <0.0001 Military 308 ( 2.1%) 203 ( 1.2%) White collar 6605 ( 44.7%) 8378 ( 50.7%) Agriculture/Fishery/Forestry/Animal husbandry 465 ( 3.1%) 579 ( 3.5%) Blue collar 3160 ( 21.4%) 2005 ( 12.1%) Student 1134 ( 7.7%) 1033 ( 6.3%) Income (NT Dollars) <10000 4314 ( 29.1%) 4803 ( 29.5%) <0.0001 10000~20000 2379 ( 16.1%) 3084 ( 18.9%) 20000~40000 4664 ( 31.5%) 4846 ( 29.8%) 40000~59999 2158 ( 14.6%) 2167 ( 13.3%) ≧60000 1307 ( 8.8%) 1384 ( 8.5%)
p-values were all calculated from Chi-square tests except for that of the variable "age". For variable "age", p-value was from Wilcoxon two sample test.
Table 2. The proportion of substance abuse for random samples of people aged 18~64 years from 2005 and 2009, frequency (%)
Variable 2005 2009 P-value N=14598 N=16563 Cigarettes 5657 ( 38.6%) 5886 ( 35.5%) <0.0001 Alcohol 7289 ( 50.4%) 9995 ( 60.4%) <0.0001 Betel nuts 3150 ( 21.4%) 3681 ( 22.2%) 0.0786 Slimming drug 501 ( 3.4%) 551 ( 3.3%) 0.7060 Cold medicine 4036 ( 27.6%) 4066 ( 24.6%) <0.0001 Sedatives 425 ( 2.9%) 180 ( 1.1%) <0.0001 Illicit drug 191 ( 1.3%) 245 ( 1.5%) 0.2197
All p-values were calculated from Chi-square tests.
Figure 2 Recent use of any illicit drug : proportion of the same age group among people aged 18~64 years from 2005 and 2009 Taiwan national survey Median age (Q1,Q3) 2005 P 2009 P non illicit drug use illicit drug use non illicit drug use illicit drug use cigarette 18 (17,21) 16 (15,18) <0.0001 18 (16,21) 16 (15,18) <0.0001 alcohol 20 (18,21) 17 (15,18) <0.0001 19 (17,22) 16 (14,18) <0.0001 Betel nuts 20 (18,25) 18 (16,20) <0.0001 20 (18,25) 18 (15,20) <0.0001 Q1: 25% qauntile Q3: 75% quantile
Betel Nuts Gateway pattern
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Table 3 The onset age of substance use in 2005 and 2009
Table 4 The relationship between the onset age of substance use and illicit drug abuse for people aged 18~64 years in Taiwan 2005 and 2009.
Variable
2005 2009
Crude OR (95% CI) *Adjusted
OR (95% CI) Crude OR (95% CI)
**Adjusted OR (95% CI) Cigarettes 0.84 ( 0.81, 0.88) 0.88 ( 0.84, 0.92) 0.85 ( 0.82, 0.88) 0.87 ( 0.84, 0.91) Alcohol 0.86 ( 0.83, 0.89) 0.88 ( 0.84, 0.91) 0.86 ( 0.84, 0.89) 0.88 ( 0.85, 0.91) Betel nuts 0.89 ( 0.86, 0.93) 0.92 ( 0.88, 0.96) 0.92 ( 0.9, 0.95) 0.95 ( 0.92, 0.98) Sedatives 0.93 ( 0.91, 0.95) 0.95 ( 0.92, 0.98)
*Odds ratio adjusted for age, sex, marital status, academic degree and academic degree of parents **Odds ratio adjusted for age, sex, marital status, academic degree of parents, occupation and income
Figure 2 The onset age of different addictive material usage among Taiwan drug users in 2009 national survey : (a) Smoke (b) Alcohol (c) Betel nuts Consumpt ion pe r pe rs on (kg ) year
Please contact with Yu-Ching Lan if you are interested in further information. yclan@mail.cmu.edu.tw
